UMEM Educational Pearls

Intubated patients may occasionally meet certain criteria for extubation while in the Emergency Department. Extubation is not without its risk, however, as up to 30% of patients have respiratory distress secondary to laryngeal and upper airway edema, with some patients requiring re-intubation.

Prior to extubation, Intensivists use a brief “cuff-leak” test (deflation of the endotracheal balloon to assess the presence or absence of an air-leak around the tube) to indirectly screen for the presence of upper airway edema and ultimately the risk of re-intubation. The cuff-leak test is performed by deflating the endotracheal balloon followed by one or more of the following maneuvers:

• Using the ventilator to measure the difference between inspired and expired tidal volumes; if there is a difference in the measured volumes, then air is “leaking” around the endotracheal tube, implying minimal airway edema.
• Auscultation for an air “leak” around the tube during mechanical ventilation; auscultation of a leak implies that air is passing around the tube and minimal airway edema is present.
• Disconnecting the patient from the ventilator and occluding the endotracheal tube during spontaneous breathing; auscultation of a leak implies that there is air passing around the tube and minimal airway edema is present.

Ochoa et al. performed a systematic review to determine the accuracy of the “cuff-leak” test to predict upper airway edema prior to extubation. The authors concluded that a positive cuff-leak test (i.e., absence of an air-leak) indicates an elevated risk of upper airway obstruction and re-intubation. A negative cuff-leak test (i.e., presence of an air-leak), however, does not reliably exclude the presence of upper airway edema or the need for subsequent re-intubation.

Bottom line: No test prior to extubation reliably predicts the absence of upper airway edema. Patients extubated in the Emergency Department require close observation with airway equipment located nearby.

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Guide-wires can be challenging to dispose of after central-line insertion because they are difficult to keep on the field, hard to place in the sharps box, and can splash nearby observers.

Click here for this little guide-wire disposal trick.

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SLAP tear/lesion – Superior labral tear anterior to posterior

Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint and is integral to shoulder stability

http://www.orthospecmd.com/images/shoulder_labral_tear_anat_02.jpg

Injury is most commonly seen in overhead throwing athletes

Or from a fall on the outstretched hand, a direct shoulder blow or a sudden pull to the shoulder

Sx’s:  A dull throbbing pain, a “catching” feeling w/ activity. Some describe clicking or locking of the shoulder. May also include nighttime symptoms. Pain is located to the anterior, superior portion of the shoulder.

Athletes may describe a significant decrease in throwing velocity

http://sitemaker.umich.edu/fm_musculoskeletal_shoulder/o_brien_s_test

Just when you think buying organic protects you from chemicals and pesticide, along comes the studies detecting arsenic in rice products and specficially in organic foods with brown rice organic sweetener. An organic toddler milk formula reportedly had 6x EPA standards for safe drinking water limit.

The more toxic arsenic is the inorganic arsenic which can cause neuropathy but after chronic exposure can cause a classic arsenic keratosis - see attached pic. The inorganic is seen commonly in seafood and is more easily excreted by the body. Unfortunately, in the study referenced here, inorganic As was the predominant type.

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1209202121_arsenickeratosis.jpg (129 Kb)

The Lung Transplant Patient in Your ED

• The number of lung transplant recipients is increasing.  With improved immunosuppressant medications, pts are living longer.  In fact, the 5-yr survival rate is now approximately 60%.
• When evaluating a lung transplant pt who is < 1 yr following transplant, think about acute rejection and infection
• Acute rejection occurs in up to 40% of pts, can present with cough, SOB, malaise, or hypoxia, and is treated with high-dose corticosteroids.
• Infection
  • Bacterial infections usually occur in the early stages following transplant, with Pseudomonas the predominant organism
  • CMV is the most common organism affecting up to 33% of pts during the first year after transplant

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Question

27 year-old woman with AIDS presents complaining of a painful, puritic, and papular rash. What's the diagnosis?

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Pericarditis is based on clinical diagnosis; typically two of four criteria are found (pleuritic chest pain, pericardial rub, diffuse ST-segment elevation, and pericardial effusion).

Treatment of pericarditis should be targeted at the cause.

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Lactate levels help to confirm septic arthritis but what about bacterial meningitis.  As reported in the daily electronic ACEP newsletter a small study of 45 patients showed that all patients with a confirmed diagnosis of bacterial meningitis had a CSF lactate level > 3.5 mmol/L.  Therefore, it might be true that viral meningitis will only have  CSF lactate levels < 3.5 mmol/L. 

With only 45 patients, this finding is clearly not ready for Prime Time but consider adding it to your next CSF study so more data can be collected on the utility of this test.

The story as seen in ACEP eNews on September 14th, 2012 is:

CSF Levels Of Lactate May Be A Marker Of Viral Versus Bacterial Meningitis.

MedPage Today (9/14, Gever) reports, "Cerebrospinal fluid (CSF) levels of lactate were a perfect marker of viral versus bacterial meningitis in a small study, a researcher reported" at the Interscience Conference on Antimicrobial Agents and Chemotherapy. Researchers found that, "among 45 adults in whom the etiology of meningitis was microbiologically confirmed, all those with CSF lactate levels above 3.5 mmol/L had the bacterial form, whereas every patient with lower levels had viral meningitis."

• sleep disruption silimar to a nightmare, but much more dramatic most often between 4-12 years
• sudden fear reaction which occurs during the transition to and from deep non-REM sleep while nightmares occur during REM sleep
• occurs 2-3 hours after falling asleep when the child suddenly awakens in distress and may thrash about, scream, cry
• child returns to sleep with no memory of the event the following morning
• often occurs when a child is stressed, overtired, on new medication, or sleeping in a new environment
• do not awaken the child during the event but rather allow them to calm on their own

Carbon monoxide (CO) and hydrogen cyanide (HCN) are two of the main gases causing injury and death from smoke inhalation in fire victims. During the first phase of a fire, and prior to depletion of oxygen reserves and subsequent production of CO, formation of HCN from the thermal breakdown of nitrogen-containing materials may be the primary cause of lethal poisoning in an enclosed-space fire.

A recent, retrospective, observational study from Poland assessed the prevalence of toxic HCN exposure in victims of enclosed-space fires.

Important findings:

• Of the 285 patients who died, 169 (59%) had detectable cyanide blood levels. 82% also had elevated carboxyhemoglobin (COHb) levels.
• Of the 40 patients who survived, 20 (50%) had detectable cyanide blood levels. All 20 had elevated COHb levels.

Conclusion: The high prevalence of coincident HCN concentrations and COHb levels in victims of enclosed-space fires emphasises the need to suspect HCN as a co-toxin in all persons rescued from fire who show signs and symptoms of respiratory distress.

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Question

40 year-old male with severe uncontrolled hypertension presents with altered mental status (head CT below). The CXR is from the same patient. What's the connection?

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Question

40 year-old male with severe uncontrolled hypertension presents with altered mental status. Head CT is shown here. Name three common anatomic locations generally seen for non-traumatic intracerebral hemorrhage. 

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Which patient has a better blood pressure, the patient with a blood pressure of 110/40 or the patient with a blood pressure of 90/60?

Mean arterial pressure (MAP) is generally considered to be the organ perfusion pressure in an individual. Because MAP requires an inconvenient calculation, we've all been taught...misled perhaps...into focusing on systolic blood pressure (SBP) as a marker of how well-perfused a patient is, and we tend to ignore the diastolic blood pressure (DBP).

It's important to remember, however, that we spend most of our lives in diastole, not systole. As a result, our organs spend more time being perfused during diastole than systole. The MAP takes this into account: MAP = (SBP + DBP + DBP)/3. DBP is more important than SBP!

So which patient is perfusing his vital organs better, the one with a BP of 110/40 or the one with a BP of 90/60? Do the MAP calculation...90/60 is better than 110/40!

Pay more attention to those diastolic BPs!

Apprehension test for patellar dislocation

Test is used to access for the possibility of a patellar dislocation, prior to evaluation, now spontaneously reduced.                                                   

Similar to the shoulder apprehension test

Designed to place the patella in a position of imminent subluxation or dislocation

http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10042-7..gr16.jpg

http://www.youtube.com/watch?v=9AJxcbd9g8A

Place the knee in 20 - 30 degrees of flexion with the quadripces relaxed. Grasp the patella and attempt to place lateral directed stress.

If the patella is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion by contracting the quadriceps

If concern arises on screening assessment, keep child in hard cervical collar and image (may start with x-ray and progress to CT if still concerned and x-rays negative).

If imaging negative, but persistent suspicion based on neurological deficits consider SCIWORA (Spinal Cord Injury WithOut Radiographic Abnormality) which exists in up to 50% of children with cervical cord injury, and may require MRI to further identify injury.

• Exposure to organophosphates can lead to “intermediate syndrome.”

• It is a syndrome characterized by weakness of neck flexors and proximal limbs, cranial nerve palsies, and respiratory muscle weakness, which can lead to respiratory paralysis.

• It follows acute cholinergic syndrome and precedes a delayed neuropathy, thus it is an “intermediate syndrome,” typically developing 24-96 hours post exposure.

• The pathophysiology of IMS remains unclear.

• Serum cholinesterase levels and electrophysiological studies are helpful in confirming the diagnosis.

• With supportive therapy, including artificial ventilation, complete recovery occurs within 5-18 days.

Right Heart Failure in the Critically Ill

• In its most simplistic form, right heart failure (RHF) is due to either to right ventricular contractile dysfunction or elevated right ventricular afterload.
  • Primary causes of RV contractile dysfunction include: coronary ischemia, sepsis, drug toxicity, and acute pulmonary hypertension
  • Primary causes of increased RV afterload include: LV dysfunction, venous thromboembolism, hypoxic pulmonary vasoconstriction, and lung injury
• Management of the patient with RHF centers on identifying and treating reversible causes, optimizing preload, inotropes, and possible implantation of a right ventricular assist device.
• Importantly, excessive volume loading can worsen RV contractile function, increase RV dilatation, and impair LV output and systemic perfusion.
• Consider early use of inotropic agents, such as dobutamine, in critically ill patients with RHF.

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Question

32 year-old female presents with 5 days of fever, chills, and flank pain. She is hypotensive on presentation and urinalysis shows pyuria. Click here for the non-contrast CT scan. What's the diagnosis and what type of antibiotics should be started empirically?

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